Delayed Cord Clamping Video

[Nathan Sundgren 40]

I wanted to let the 99nicu community have the first look at my latest video. It is based on a ground rounds talk I gave on delayed cord clamping several months ago. I updated it and added lots of animation. You can find the video by following this link: https://youtu.be/6qA3CVGp5Sw

The video is not public, meaning you can not search for it, but you can follow the link to view it. I'd appreciate any thoughts on the video, especially mistakes you see or if you felt anything I said was misleading about the evidence. Post your comments to this forum and I will respond. I'm hoping to make the video public depending on this communities comments.

Also, I feel a bit weird posting or doing anything not COVID19 related these days, but maybe this can be one thing that takes the mind off of the current pandemic for about 16 minutes of your time.

-Nathan

[olamedmac 20]

Dear Nathan, what a tremendous work you have done, and the video is very informative and I hope you will in due time put it official, and I would be glad to share it in the future, after some revisions. I do realize that choosing what references to mention is a difficult task, and it is clear that you have done your your share of reading. Although, I you ask for comments, here are mine (they grew quite lengthy...):

You mention/cite Charles Darwin's kid Erasmus, and it says 1801on the slide. Erasmus (b 1731 - d 1802, https://en.wikipedia.org/wiki/Erasmus_Darwin) was actually Charles (b 1809 d 1882, https://en.wikipedia.org/wiki/Charles_Darwin) grandfather.

I don't remember my source, but I´ve somewhere been informed that the Aristotle quote is false, and is not to be found in his writing. As I havn´t had the time to read through the  writings of Aristotele myself, I cautiously avoid this citation in my own presentations. Especially if American, I would choose to cite the pioneer of perinatal medicine in North America, William Potts Dewees (https://en.wikipedia.org/wiki/William_Potts_Dewees)  A compendious system of midwifery. 2nd Edn. Philadelphia: Carey and Lea, 1826: "”When respiration is established /.../we apply a ligature to the cord, provided pulsation has ceased in it; but not until then”. Please see the attached article on Dr Dewees.

As for benefits in term infants, I'm a little surprised that our paper on 4-year extensive development follow-up is not mentioned, as it was that paper that ACOG cites in their new recommendations from 2017: Andersson O, Lindquist B, Lindgren M, Stjernqvist K, Domellöf M, Hellström-Westas L. Effect of Delayed Cord Clamping on Neurodevelopment at 4 Years of Age: A Randomized Clinical Trial. JAMA Pediatr. 2015;169(7):631-8. http://dx.doi.org/10.1001/jamapediatrics.2015.0358. In this, newborns were randomized to either delayed (>180 s) or immediate (<10 s) cord clamping, and we concluded that Delayed CC compared with early CC improved scores in the fine-motor and social domains at 4 years of age

When it comes to term transition, you mention the observational study by Smit & al on 109 infants. Last may, we published a RCT including 1264 newborns randomized to either < 60 s or > 180 and could show the same results: the delayed group had higher oxygen saturation up to 10 minutes after birth, and a lower heart rate at 1 and 5 minutes. Actually DCC newborns started breathing earlier and had a slightly higher (but significant) Apgar score at 1, 5 and 10 minutes. I believe this study might be mentioned: KC, A., Singhal, N., Gautam, J. et al. Effect of early versus delayed cord clamping in neonate on heart rate, breathing and oxygen saturation during first 10 minutes of birth - randomized clinical trial. matern health, neonatol and perinatol 5, 7 (2019). https://doi.org/10.1186/s40748-019-0103-y

As for the discussion on when to clamp the cord on term infants, I'm really sad to find that you endorse the notion that one minute is enough. In the Yao reference you mention, there is i slight improvement also between 1 and 3 minutes.

I'm not sure if it is the following paper you cite; Chen, X., Li, X., Chang, Y. et al. Effect and safety of timing of cord clamping on neonatal hematocrit values and clinical outcomes in term infants: A randomized controlled trial. J Perinatol 38, 251–257 (2018). https://doi.org/10.1038/s41372-017-0001-y, but if it is, there is at least a trend for additional improvement up to 3 minutes. Ceriani Cernadas compare immediate, 1 minute and 3 minutes and found significant improvement between 1 min and 3 min (Ceriani Cernadas JM, Carroli G, Pellegrini L, Otaño L, Ferreira M, Ricci C, et al. The Effect of Timing of Cord Clamping on Neonatal Venous Hematocrit Values and Clinical Outcome at Term: A Randomized, Controlled Trial. Pediatrics. 2006;117(4):e779-e86.) The continuous weighing study by Farrar et al.   show the same results as Yao and they conclude: Placental transfusion was usually complete by 2 minutes, but sometimes continued for up to 5 minutes. Farrar D, Airey R, Law G, Tuffnell D, Cattle B, Duley L. Measuring placental transfusion for term births: weighing babies with cord intact. BJOG 2011;118:70–75.

Our studies in Nepal compare < 60 s and 3 minutes, etc etc. Please join the science and recommend at least 3 minutes - no side effects have been shown!

Well, this was my immediate comments; I do admire your effort and wish you all luck on helping to spread the benifits of keeping the umbilical cord intact.

 

 

 

 

Arch Dis Child Fetal Neonatal Ed-1996-Dunn-F69-70[1]_William Potts Dewees (1768-1841).pdf Andersson et al-2015-Jama Pediatrics.pdf Kc_MHNP_2019_effects_DCC.pdf Ashish et al-2017-Jama Pediatrics.pdf

[Stefan Johansson 741]

I am not an expert like @olamedmac so I cannot comment on the content as such, but I think the structure is excellent and format is superb! Do you do the animated graphics yourself?

Great initiative, IMHO delayed cord clamping is one of the most low-hanging fruits in neonatal care.

Somewhat OT: as we had to cancel our yearly conference due to the pandemic, we have discussed to arrange short webinars. @Nathan Sundgren would you like to present about Cord clamping over ~15-20 min in such a format?

 

[Nathan Sundgren 40]

@olamedmac what a privilege to have you respond to this thread. Thank you. I will definitely make some revisions based on your suggestions. I was nervous about the Aristotle quote, since his work is all Greek to me, but I thought I had it from a reputable source that it was true. Your suggested quote is many times better. I really thought I had the Erasmus - Charles Darwin connection correct, but I should have double checked my facts there, too. I will also fix this. 

As you said, deciding which articles to include does get tricky as I was really working hard to keep the video to 15-20 minutes long, and usually the shorter the better. I will look again at including some of your suggestions.

As for the 60 second recommendation, I wholeheartedly agree with you about 3 minutes in term babies. Honestly, as a neonatologist, my mind is mostly thinking of the preterm babies. I do think right now that 60 seconds is probably the best compromise for preterm babies, especially since not many are resuscitating on the open cord. I need to make a better distinction in recommendations for preterm to term. I did try to express this by saying a few times in the video to consider longer for stable term babies. I think you are right that I can make a stronger statement for the term babies being 3 minutes. 

@Stefan Johansson the webinar idea sounds great and I'd love to give it a try. Thanks. Maybe we can DM on twitter for more discussion?

[Stefan Johansson 741]

@Nathan Sundgren I send you a DM on Tw!

[olamedmac 20]

@Nathan Sundgren I'm glad you liked my suggestion to cite William Potts Dewees 🙂 I do understand that most of us as neonatologists have our minds set to the most vulnerable among our patients - there're many reasons for that. And I think that's why I mainly perform research in an area that's almost pristine: term infants, where seemingly healthy or less vulnerable babies won't have noticeable advantages, but as they are millions, even small improvements will have a massive effect on a global scale.

I look forward to your revision of the video - once again, the video is very informative and you have done a great job.

[Nathan Sundgren 40]

Final video version now public on YouTube. Please share with interested colleagues. 

 

[yangw126 19]

Would you please send me your final video version  by E-mail ( w.yang126@126.com)?   Thanks a lot ！

[skinmond 10]

Great video, well done! Looking forward to webinar. Re the Aristotle quote, you can get his complete works translated into English as an e-book - fascinating to dip into it! The quote you're looking for is on P. 1716 - "The History of Animals" Book VII section 10.

[prakashmanikoth 2]

Excellent multimedia summary of cord clamping backed by evidence